Article, Surgery

Ascaris as a leading point for small-bowel intussusception in an adult: a rare cause of intussusception

American Journal of Emergency Medicine (2008) 26, 381.e3-381.e4

Case Report

Ascaris as a leading point for small-bowel intussusception in an adult: a rare cause of intussusception

Abstract

adult intussusception represents 1% of patients with bowel obstructions and requires a surgical approach. Malignancy is associated with 31% of small bowel intussusception and 70% of large bowel intussusception. Intestinal intussusception caused by ascaris, however, is very uncommon. This report describes our experience of this rare cause of intussusception and its clinical findings.

Intussusceptions are rare in adult population, and the variety of different presenting symptoms makes the diag- nosis difficult. The cause of intussusceptions differs between pediatric and adult populations. In children, a precipitating lesion is found in only 10% of patients, whereas in adults, an underlying cause is present 90% of the time [1-3]. Although vomiting, bloody stools, abdominal pain, and mass are often considered the main symptoms found in children with intussusception, the presenting symptoms in adult patients with intussusceptions are often nonspecific and episodic. Ultrasonography and computed tomography (CT) prove to be the most effective preoperative diagnostic methods [2,3]. We present the diagnosis and management of adult intussusception due to ascaris.

A 62-year-old woman presented with severe abdominal pain and bile-stained vomiting of 3 days’ duration. On palpation there was distended abdomen, diffuse abdominal tenderness and guarding with peritoneal irritation, and a decrease in bowel sounds. No masses were palpable. Her medical history should no remarkable feature. Her body temperature was 37?C. Laboratory findings were as follows: white blood cell count, 12 600; hemoglobin level,

12.3 gm/dL; platelets, 200000. All other results, including electrolytes and urinalysis, were within normal limits. abdominal radiography showed air-fluid levels indicative of a Small bowel obstruction. Computed tomography revealed typical stratification of the bowel walls and a multilayered appearance in longitudinal section and target sign in cross section (Fig. 1). After appropriate resuscitation, she underwent an explorative laparotomy. During the surgical intervention an ileoileal intussusception due to ascaris was observed. A necrotic ileal loop filled with ascaris worms was found. A small bowel resection without reduction of the intussusception was performed. Residual ascaris worms were milked from the open bowel ends (Fig. 2). The patient made an uneventful recovery.

Adult intussusception occurs infrequently and differs from childhood intussusception in its presentation, etiology, and treatment. Diagnosis can be delayed because of its longstanding, intermittent, and nonspecific symptoms, and most cases are diagnosed at emergency laparotomy [4,5]. Unlike intussusception in the pediatric population, the

Fig. 1 Computed tomography shows typical stratification of the bowel walls and a multilayered appearance (white arrow) in longitudinal section (A) and target sign (white arrow) in cross section (B). Proximal bowel loops are dilated due to obstruction. This bowel-within-bowel appearance is consistent with invagination.

0735-6757/$ – see front matter (C) 2008

381.e4 Case Report

usually are those of bowel obstruction and, consequently, intussusception is often initially misdiagnosed in the adult population.

Oguzhan Karatepe MD

Department of General Surgery Okmeydani Training and Research Hospital

Istanbul 34394, Turkey E-mail address: [email protected]

Fig. 2 A, Resected necrotic specimen of the intussusception. The white arrow shows the invagination point; the black arrow shows the ascaris in the necrotic small bowel segment. B, Ascaris worms milked from the open bowel ends.

classical triad of palpable sausage, current jelly stools, and pain are rarely evident and a demonstrable etiology is found in 70% to 90% of cases in the adult population [3,4]. Sonography and CT are very appropriate and useful in the diagnosis. These imaging modalities reveal a pseudokidney sign and a target sign, with an edema of Kerckring folds, and complex hyperechoic mass [4,5].

The intussusceptions have been classified into 4 cate- gories according to the site of origin: enteric, ileocolic, ileocaecal, and colonic. Ileoileal or colonic intussusception is uncommon in infants but is frequent in adults [1-3]. The lead points for the intussusceptions are attributable to benign, malignant, or idiopathic causes. Large bowel Lead points were more frequently malignant than small bowel lead points. Treatment usually involves laparotomy and resection of the affected segment, because in adults there is almost always an organic cause [3,4].

The nature of the lead of the invagination varies greatly including polyps, hamartomas, lipomas, leiomyomas, neuro- fibromas, adenomas, inflammatory polyps, tuberculosis, Meckel’s diverticulum, and adhesions [4-7]. A very rare cause of adult intussusception is Ascaris lumbricoides infes- tation. A lumbricoides is 1 of the largest of parasites in the human bowel. The worms usually develop in the jejunum and can reach several thousand in number, causing bowel obstruction, volvulus, intussusception, appendicitis, and even bowel perforation with penetration into the peritoneal cavity [6,7].

In conclusion, although ultrasonography and CT may help in reaching a diagnosis, the predominant symptoms

Mustafa Tukenmez MD Kemal Hunerli MD Gamze Citlak MD

Department of General Surgery Istanbul Medical Faculty Istanbul University Istanbul 34093, Turkey

Artur Salmaslioglu MD Department of Radiology Istanbul Medical Faculty Istanbul University Istanbul 34093, Turkey

Muharrem Battal MD

Department of General Surgery Okmeydani Training and Research Hospital

Istanbul 34394, Turkey

Yesim Erbil MD Department of General Surgery Istanbul Medical Faculty Istanbul University

Istanbul 34093, Turkey

doi:10.1016/j.ajem.2007.05.022

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